The Case

A 67-year-old woman presents with sudden onset of right-sided hemiparesis and facial droop. She takes aspirin daily. The noncontrast head CT shows a hemorrhagic stroke. Would a platelet transfusion be of benefit?

Background

Antiplatelet therapy prior to a hemorrhagic stroke raises the risk of death by 27 percent, and more than 25 percent of patients with intracerebral hemorrhages (ICHs) were taking antiplatelet therapy.¹

Reversal of antiplatelet medications in patients with ICH was addressed in a publication by Martin and Conlon.² They stated, “None of these studies showed a mortality benefit or improved functional outcome with platelet transfusion in patients with spontaneous or traumatic intracerebral hemorrhage who were receiving antiplatelet medications.”

They also said there are “no compelling data currently supporting the use of platelet transfusion” and that “it would be within the standard of care to withhold platelet transfusion in patients with either spontaneous or traumatic intracerebral hemorrhage who are receiving antiplatelet therapy.” The review did note that the existing evidence at the time was all based on relatively small retrospective studies.

The recommendation from the neurosurgical perspective states, “At present, the literature contains insufficient information to establish any guidelines or treatment recommendations. Considering this, the current authors have proposed a protocol for antiplatelet reversal in both spontaneous and traumatic acute ICH.”³

Clinical Question

In patients with acute nontraumatic hemorrhagic stroke, does platelet transfusion reduce death or disability?

Reference

Baharoglu MI, Cordonnier C, Al-Shahi Salman R, et al. Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial. Lancet. 2016;387(10038):2605-2613.

• Population: Adults 18 years or older with nontraumatic ICH with a Glasgow Coma Scale rating of greater than 7 in whom platelets could be transfused within six hours of symptom onset and who used antiplatelet therapy for at least seven days.
• Exclusions: Epidural or subdural hematoma, underlying aneurysm or arteriovenous malformation, planned surgery within 24 hours, intraventricular blood more than sedimentation in the posterior horns, previous adverse reaction to platelet transfusion, known use of vitamin K antagonists or history of coagulopathy, known thrombocytopenia, lacking mental capacity, or death appeared imminent.
• Intervention: Platelet transfusions within six hours of supratentorial ICH symptom onset and within 90 minutes of diagnostic brain imaging.
• Comparison: Standard care.
• Outcomes:
  • Primary: A shift toward death or dependence scored with the modified Rankin Scale (mRS) at three months.
  • Secondary: Survival, poor outcome (mRS 4–6), poor outcome (mRS 3–6), hemorrhage growth after 24 hours, transfusion issues (reactions and thrombotic complications), and other serious adverse events.

Authors’ Conclusion

“Platelet transfusion seems inferior to standard care for people taking antiplatelet therapy before intracerebral hemorrhage. Platelet transfusion cannot be recommended for this indication in clinical practice.”

Key Results

The study included 190 patients randomized, with 97 in the platelet transfusion group and 93 in the standard care group. The mean patient age was 74 years.

Primary Outcome:

• Odds of death or dependence (mRS 4–6) were greater in the platelet transfusion group.
• Unadjusted odds ratio of mRS 4–6 was 1.84 (95% CI; 1.10–3.08, P=0.02) in the platelet transfusion group.
• Adjusted odds ratio of mRS 4–6 was 2.05 (95% CI; 1.18–3.56, P=0.0114) in the platelet transfusion group.

Secondary Outcomes:

• Alive at three months: 68% in the platelet transfusion group versus 77% in the standard care group; odds ratio 0.62 (95% CI; 0.33–1.19, P=0.15).
• mRS 4–6 at three months: 72% versus 56%; odds ratio 2.04 (95% CI; 1.12–3.74, P=0.0195).
• mRS 3–6 at three months: 89% versus 82%; odds ratio 1.75 (95% CI; 0.77–3.97, P=0.18).
• Median ICH growth at 24 hours (mL): 2.01 (0.32–9.34) in the platelet transfusion group (n=80) versus 1.16 (0.03–4.42) in the standard care group (n=73) (P=0.81).

Transfusion Issues: One patient had a minor transfusion reaction; there was no difference in thrombotic complications (four in platelet transfusion group versus one in standard care).

Serious Adverse Events: 42% in the platelet transfusion group versus 29% in the standard care group; odds ratio 1.79 (95% CI; 0.98–3.27) in the intention-to-treat analysis.

Evidence-Based Medicine Commentary

Emergency Department Patients: It is not clear if these patients were ED patients as it was not explicitly stated in the paper. It seems likely that they were given the nature of the complaint.

Consecutive Recruitment: There was no documentation on whether the patients were recruited consecutively. The publication does say that PATCH investigators did not need to keep a screening log. Therefore, we are unable to know if there was selection bias.

Additional Data: The authors say in their discussion that a similar randomized control trial is nearing completion. ClinicalTrials.gov shows that no results are available, and the page says, “The recruitment status of this study is unknown. The completion date has passed, and the status has not been verified in more than two years.”⁴

Bottom Line: Transfusion of platelets in patients with nontraumatic intracerebral hemorrhage cannot be recommended based on the available evidence.

Case Resolution

You discuss the care with the patient and her family. Neurosurgery is contacted, no platelets are transfused, and she is transferred to the intensive care unit.

Thank you to Dr. Robert Edmonds, an emergency medicine staff physician in Newport News, Virginia, and a recent graduate of the University of Missouri-Kansas City emergency medicine residency. (Disclaimer: The views and opinions of this article do not reflect the views and opinions of the US Air Force, the United States government, or Langley Air Force Base.)

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

References

1. Thompson BB, Béjot Y, Caso V, et al. Prior antiplatelet therapy and outcome following intracerebral hemorrhage: a systematic review. Neurology. 2010;75(15):1333-1342.
2. Martin M, Conlon LW. Does platelet transfusion improve outcomes in patients with spontaneous or traumatic intracerebral hemorrhage? Ann Emerg Med. 2013;61(1):58-61.
3. Campbell PG, Sen A, Yadla S, et al. Emergency reversal of antiplatelet agents in patients presenting with an intracranial hemorrhage: a clinical review. World Neurosurg. 2010;74(2-3):279-285.
4. Platelet transfusion in acute intracerebral hemorrhage. ClinicalTrials.gov website. Accessed Aug. 17, 2017.